Patient engagement to counter catheter-associated urinary tract infections with an app (PECCA): a multicentre, prospective, interrupted time-series and before-and-after study

BACKGROUND

The risk of urinary tract infections (UTIs) is increased by unnecessary placement and prolonged use of urinary catheters.

AIM

To assess whether inappropriate use of catheters and catheter-associated UTI were reduced through patient participation.

METHODS

In this multicentre, interrupted time-series and before-and-after study, we implemented a patient-centred app which provides catheter advice for patients, together with clinical lessons, feedback via e-mails and support rounds for staff members. Data on catheter use and infections were collected during a six-month baseline and a six-month intervention period on 13 wards in four hospitals in the Netherlands. Dutch Trial Register: NL7178.

FINDINGS

Between June 25th, 2018 and August 1st, 2019, 6556 patients were included in 24 point-prevalence surveys, 3285 (50%) at baseline and 3271 (50%) during the intervention. During the intervention 249 app users and a median of seven new app users per week were registered (interquartile range: 5.5-13.0). At baseline, inappropriate catheter use was registered for 175 (21.9%) out of 798 catheters, compared to 55 (7.0%) out of 786 during the intervention. Time-series analysis showed a non-significant decrease of inappropriate use of 5.8% (95% confidence interval: -3.76 to 15.45; P = 0.219), with an odds ratio of 0.27 (0.19-0.37; P < 0.001). Catheter-associated UTI decreased by 3.0% (1.3-4.6; P = 0.001), with odds ratio 0.541 (0.408-0.716; P < 0.001).

CONCLUSION

Although UTI significantly decreased after the implementation, patient participation did not significantly reduce the prevalence of inappropriate urinary catheter use. However, the inappropriate catheter reduction of 5.8% and an odds ratio of 0.27 suggest a positive trend. Patient participation appears to reduce CAUTI and could reduce other healthcare-associated infections.

Qualitative study on shared decision making in cystitis management in general practice

BACKGROUND

Cystitis are commonly treated with antibiotics, although non-antibiotic options could be considered for healthy non-pregnant women. Shared decision making (SDM) can be used in cystitis management to discuss the various treatment options but is not frequently applied in general practice.

AIM

Identifying barriers and facilitators for applying SDM in cystitis management in general practice.

DESIGN & SETTING

Qualitative explorative research in general practice with healthcare professionals (HCPs; general practitioners (GPs) and GP assistants) and healthy non-pregnant women with a recent history of cystitis (patients).

METHOD

Individual semi-structured interviews were conducted between May and October 2022. We applied a combination of thematic and framework analysis.

RESULTS

Ten GPs, seven GP assistants, and fifteen patients were interviewed. We identified three main barriers and one key facilitator: 1) applying SDM is deemed inefficient; 2) HCPs presume that patients expect antibiotic treatment and some HCPs consider non-antibiotic treatment inferior; 3) Patients are largely unaware of the various non-antibiotic treatment options for cystitis; 4) HCPs recognise some benefits of applying SDM in cystitis management, including reduced antibiotic use and improved patient empowerment, and patients appreciate involvement in treatment decisions, but preferences for SDM vary.

CONCLUSION

SDM is infrequently applied in cystitis treatment in general practice due to the current efficient cystitis management, HCPs' perceptions, and patient unawareness. Nevertheless, both HCPs and patients recognise the long-term benefits of applying SDM in cystitis management. Our findings facilitate the development of tailored interventions to increase the application of SDM which should be co-created with HCPs and patients and fit into the current efficient cystitis management.

A reference standard for urinary tract infection research: a multidisciplinary Delphi consensus study

The absence of a consensus-based reference standard for urinary tract infection (UTI) research adversely affects the internal and external validity of diagnostic and therapeutic studies. This omission hinders the accumulation of evidence for a disease that imposes a substantial burden on patients and society, particularly in an era of increasing antimicrobial resistance. We did a three-round Delphi study involving an international, multidisciplinary panel of UTI experts (n=46) and achieved a high degree of consensus (94%) on the final reference standard. New-onset dysuria, urinary frequency, and urinary urgency were considered major symptoms, and non-specific symptoms in older patients were not deemed indicative of UTI. The reference standard distinguishes between UTI with and without systemic involvement, abandoning the term complicated UTI. Moreover, different levels of pyuria were incorporated in the reference standard, encouraging quantification of pyuria in studies done in all health-care settings. The traditional bacteriuria threshold (105 colony-forming units per mL) was lowered to 104 colony-forming units per mL. This new reference standard can be used for UTI research across many patient populations and has the potential to increase homogeneity between studies.

Virological failure after switch to long-acting cabotegravir and rilpivirine injectable therapy: an in-depth analysis

BACKGROUND

Long-acting (LA) injectable therapy with cabotegravir (CAB) and rilpivirine (RPV) is currently used as maintenance treatment for HIV-1, and has a low risk for virological failure (VF). Although the risk is low, the circumstances and impact of VF in the real-world setting merits further evaluation.

METHODS

We performed an in-depth clinical, virological and pharmacokinetic analysis on the reasons behind, and the impact of VF during LA CAB/RPV therapy in five cases from the Netherlands. Genotypic resistance testing was performed after the occurrence of VF and drug plasma (trough) concentrations were measured after VF was established and on any other samples to assess on-treatment drug levels. CAB and RPV drug levels that were below the first quartile of the population cut-off (

RESULTS

Five cases who were eligible for LA CAB/RPV experienced VF despite a low predicted risk at baseline. Genotypic resistance testing revealed extensive selection of non-nucleoside reverse transcriptase inhibitor associated mutations in all, and integrase strand transfer inhibitor mutations in four cases. All cases displayed low drug levels of either CAB, RPV or both during the treatment course, likely contributing to the occurrence of VF. In three cases, we were able to identify the potential mechanisms behind these low drug levels.

CONCLUSIONS

This is the first in-depth multiple case analysis of VF on LA CAB/RPV therapy in a real-world setting. Our observations stress the need to be aware for (evolving) risk factors and the yield of a comprehensive clinical, virological and pharmacokinetic approach in case of failure.

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Key Words

• Long-acting
• cabotegravir
• injectables
• rilpivirine
• virological failure

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MESH Headings Collapse

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A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes

OBJECTIVES

To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention.

DESIGN

Mixed-methods process evaluation study.

SETTING AND PARTICIPANTS

Physicians, nursing staff, client council members, and residents of Dutch NHs.

METHODS

We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members.

RESULTS

Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture.

CONCLUSIONS AND IMPLICATIONS

Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.

Optimising HIV care using information obtained from PROMs: protocol for an observational study

INTRODUCTION

Successful antiviral therapy has transformed HIV infection into a chronic condition, where optimising quality of life (QoL) has become essential for successful lifelong treatment. Patient-reported outcome measures (PROMs) can signal potential physical and mental health problems related to QoL. This study aims to determine whether PROMs in routine clinical care improve quality of care as experienced by people with HIV (PWH).

METHODS AND ANALYSIS

We report the protocol of a multicentre longitudinal cohort studying PWH at Amsterdam University Medical Centres in the Netherlands. PROMs are offered annually to patients via the patient portal of the electronic health record. Domains include anxiety, depression, fatigue, sleep disturbances, social isolation, physical functioning, stigma, post-traumatic stress disorder, adherence, drug and alcohol use and screening questions for sexual health and issues related to finances, housing and migration status. Our intervention comprises (1) patients' completion of PROMs, (2) discussion of PROMs scores during annual consultations and (3) documentation of follow-up actions in an individualised care plan, if indicated. The primary endpoint will be patient-experienced quality of care, measured by the Patient Assessment of Chronic Illness Care, Short Form (PACIC-S). Patients will provide measurements at baseline, year 1 and year 2. We will explore change over time in PACIC-S and PROMs scores and examine the sociodemographical and HIV-specific characteristics of subgroups of patients who participated in all or only part of the intervention to ascertain whether benefit has been achieved from our intervention in all subgroups.

ETHICS AND DISSEMINATION

Patients provide consent for the analysis of data collected as part of routine clinical care to the AIDS Therapy Evaluation in the Netherlands study (ATHENA) cohort through mechanisms described in Boender et al. Additional ethical approval for the analysis of these data is not required under the ATHENA cohort protocol. The results will be presented at national and international academic meetings and submitted to peer-reviewed journals for publication.

The Risk of Preterm Birth in Low Risk Pregnant Women with Urinary Tract Infections

OBJECTIVE

Urinary tract infections are among the most common infections during pregnancy. The association between symptomatic lower urinary tract infections during pregnancy and fetal and maternal complications such as preterm birth and low birthweight remains unclear. The aim of this research is to evaluate the association between urinary tract infections during pregnancy and maternal and neonatal outcomes, especially preterm birth.

STUDY DESIGN

This study is a secondary analysis of a multicenter prospective cohort study, which included patients between October 2011 and June 2013. The population consists of women with low risk singleton pregnancies. We divided the cohort into women with and without a symptomatic lower urinary tract infection after 20 weeks of gestation. Baseline characteristics and maternal and neonatal outcomes were compared between the two groups. Multivariable logistic regression analysis was used to correct for confounders. The main outcome was spontaneous preterm birth at <37 weeks.

RESULTS

We identified 4,918 pregnant women eligible for enrollment, of whom 9.4% had a symptomatic lower urinary tract infection during their pregnancy. Women with symptomatic lower urinary tract infections were at increased risk for both preterm birth in general (12 vs. 5.1%, adjusted OR 2.5; 95% CI 1.7-3.5) as well as a spontaneous preterm birth at <37 weeks (8.2 vs. 3.7%, adjusted OR 2.3; 95% CI 1.5-3.5). This association was also present for early preterm birth at <34 weeks. Women with symptomatic lower urinary tract infections during pregnancy are also at increased risk of endometritis (8.9 vs. 1.8%, adjusted OR 5.3; 95% CI 1.4-20) and mastitis (7.8 vs. 1.8%, adjusted OR 4.0; 95% CI 1.6-10) postpartum.

CONCLUSION

Low risk women with symptomatic lower urinary tract infections during pregnancy are at increased risk of spontaneous preterm birth. In addition, an increased risk for endometritis and mastitis postpartum was found in women with symptomatic lower urinary tract infection during pregnancy.

KEY POINTS

· UTIs increase the risk of preterm birth.. · UTIs increase the risk of endometritis postpartum.. · UTIs increase the risk of mastitis postpartum..

Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial

BACKGROUND

Severe fatigue following coronavirus disease 2019 (COVID-19) is prevalent and debilitating. This study investigated the efficacy of cognitive-behavioral therapy (CBT) for severe fatigue following COVID-19.

METHODS

A multicenter, 2-arm randomized controlled trial was conducted in the Netherlands with patients being severely fatigued 3-12 months following COVID-19. Patients (N = 114) were randomly assigned (1:1) to CBT or care as usual (CAU). CBT, targeting perpetuating factors of fatigue, was provided for 17 weeks. The primary outcome was the overall mean difference between CBT and CAU on the fatigue severity subscale of the Checklist Individual Strength, directly post-CBT or CAU (T1), and after 6 months (T2). Secondary outcomes were differences in proportions of patients meeting criteria for severe and/or chronic fatigue, differences in physical and social functioning, somatic symptoms, and problems concentrating between CBT and CAU.

RESULTS

Patients were mainly nonhospitalized and self-referred. Patients who received CBT were significantly less severely fatigued across follow-up assessments than patients receiving CAU (-8.8 [95% confidence interval {CI}, -11.9 to -5.8]); P < .001), representing a medium Cohen's d effect size (0.69). The between-group difference in fatigue severity was present at T1 (-9.3 [95% CI, -13.3 to -5.3]) and T2 (-8.4 [95% CI, -13.1 to -3.7]). All secondary outcomes favored CBT. Eight adverse events were recorded during CBT, and 20 during CAU. No serious adverse events were recorded.

CONCLUSIONS

Among patients, who were mainly nonhospitalized and self-referred, CBT was effective in reducing fatigue. The positive effect was sustained at 6-month follow-up.

CLINICAL TRIALS REGISTRATION

Netherlands Trial Register NL8947.

Adherence to preventive measures after SARS-CoV-2 vaccination and after awareness of antibody response in kidney transplant recipients in the Netherlands: a nationwide questionnaire study

Background

Kidney transplant recipients (KTRs) were advised to tightly adhere to government recommendations to curb the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) because of a high risk of morbidity and mortality and decreased immunogenicity after vaccination. The aim of this study was to analyse the change in adherence to preventive measures after vaccination and awareness of antibody response, and to evaluate its effectiveness.

Methods

In this large-scale, national questionnaire study, questionnaires were sent to 3531 KTRs enrolled in the Dutch RECOVAC studies, retrospectively asking for adherence to nine preventive measures on a 5-point Likert scale before and after SARS-CoV-2 vaccination and after awareness of antibody response. Blood samples were collected 28 days after the second vaccination. Antibody response was categorised as non-responder (≤50 BAU/mL), low-responder (>50 ≤ 300 BAU/mL) or high-responder (>300 BAU/mL), and shared with participants as a correlate of protection. Participants of whom demographics on sex and age, blood samples and completed questionnaires were available, were included. Our study took place between February 2021 and January 2022. The primary outcome of adherence before and after vaccination was assessed between August and October 2021 and compared via the Wilcoxon signed rank sum test. Logistic regression analysis was performed to estimate the association between antibody response and non-adherence, and adherence on acquiring SARS-CoV-2 infection. This study is registered at ClinicalTrials.gov (NCT04841785).

Findings

In 2939 KTRs (83%) who completed the first questionnaire on adherence to preventive measures, adherence was higher before than after vaccination (4.56, IQR 4.11-4.78 and 4.22, IQR 3.67-4.67, p < 0.001). Adherence after awareness of antibody response was analysed in 2399 KTRs (82%) of whom also blood samples were available, containing 949 non-responders, 500 low-responders and 950 high-responders. Compared to non-responders, low- and high-responders reported higher non-adherence. Higher adherence was associated with lower infection rates before and after vaccination (OR 0.67 [0.51-0.91], p = 0.008 and OR 0.48 [0.28-0.86], p = 0.010).

Interpretation

Adherence decreased after SARS-CoV-2 vaccination and in KTRs who were aware of a subsequent antibody response compared with those without. Preventive measures in this vulnerable group seem to be effective, regardless of vaccination status. This study starts a debate on sharing antibody results with the patient and future studies should elucidate whether decreased adherence in antibody responders is justified, also in view of future pandemics.

Funding

The Netherlands Organization for Health Research and Development and the Dutch Kidney Foundation.

Definitions of Urinary Tract Infection in Current Research: A Systematic Review

Defining urinary tract infection (UTI) is complex, as numerous clinical and diagnostic parameters are involved. In this systematic review, we aimed to gain insight into how UTI is defined across current studies. We included 47 studies, published between January 2019 and May 2022, investigating therapeutic or prophylactic interventions in adult patients with UTI. Signs and symptoms, pyuria, and a positive urine culture were required in 85%, 28%, and 55% of study definitions, respectively. Five studies (11%) required all 3 categories for the diagnosis of UTI. Thresholds for significant bacteriuria varied from 103 to 105 colony-forming units/mL. None of the 12 studies including acute cystitis and 2 of 12 (17%) defining acute pyelonephritis used identical definitions. Complicated UTI was defined by both host factors and systemic involvement in 9 of 14 (64%) studies. In conclusion, UTI definitions are heterogeneous across recent studies, highlighting the need for a consensus-based, research reference standard for UTI.

Exploring nurses' role in guiding residents' workplace learning: A mixed-method study

INTRODUCTION

Understanding residents' workplace learning could be optimized by not only considering attending physicians' role but also the role of nurses. While previous studies described nurses' role during discrete activities (e.g. feedback), a more profound understanding of how nurses contribute to residents' learning remains warranted. Therefore, we used the educational concept of guidance and explored the extent to which residents' and nurses' perceptions align regarding nurses' guiding role and which reasons they provide for their perceptions.

METHODS

This mixed-method study was conducted at four Dutch university medical centres in 2021. We simultaneously collected quantitative and qualitative data from 103 residents and 401 nurses through a theory-informed questionnaire with a Likert-scale and open-ended questions. We analyzed quantitative data to explore respondents' perceptions of nurses' guiding role by using anova. The thematically analyzed qualitative open comments explored respondents' reasons for their perceptions.

RESULTS

Nurses indicated to provide significantly more support (p = .01) and guidance on learning from patient care (p < .01) than perceived by residents. Moreover, nurses indicated that attending physicians did not always involve them in guiding residents, whereas residents perceived nurses were being involved (p < .001). Themes suggest that nurses and residents could be divided into two groups: (i) respondents who felt that guiding was inextricably linked to good interprofessional collaboration and patient care and (ii) respondents who saw the guiding role as limited and emphasised the distinct fields of expertise between nurses and physicians.

CONCLUSIONS

Residents and nurses felt that nurses played an important role in guiding residents' workplace learning. However, some residents did not always perceive to be guided. To further capitalise on nurses' guiding role, we suggest that residents can be encouraged to engage in the learning opportunities nurses provide to achieve optimal team-based patient care.

Pharmacokinetic/Pharmacodynamic Target Attainment of Ceftazidime in Adult Patients on General Wards with Different Degrees of Renal Function: A Prospective Observational Bicenter Cohort Study

No prospective evidence exists on the pharmacokinetic/pharmacodynamic (PK/PD) target attainment of ceftazidime in adult patients on general wards. We aimed to investigate whether the PK/PD target of ceftazidime (50% T > MIC) is attained in adult patients on general wards with adequate and impaired renal function receiving regular and guideline-recommended reduced doses of ceftazidime. In this observational, prospective, bicenter cohort study, adult patients admitted to a general ward receiving ceftazidime as part of standard care were included. Three blood samples per patient within 72 h after start of treatment were collected. Data were analyzed with nonlinear mixed effects modeling. The primary endpoint was target attainment of 50% T > MIC during the first 24 h of treatment (50% T0–24 > MIC). Forty patients were included from whom 121 blood samples were obtained. All 25/25 patients with adequate renal function, 9/10 patients with moderately impaired renal function (eGFR 30–50 mL/min/1.73 m2) and 5/5 patients with severe impaired renal function (eGFR < 30 mL/min/1.73 m2) attained 50% T0–24 > MIC when applying the clinical breakpoint MIC for Pseudomonas aeruginosa of 8 mg/L. The one patient not attaining the PK/PD target did not differ in any of the collected patients’ characteristics, except that this patient was the oldest in the study population. However, age was not statistically significantly associated with clearance or volume of distribution in the population pharmacokinetic model and, therefore, not likely the cause for this patient not attaining the PK/PD target. Our results suggest ≥90% probability of the PK/PD target attainment of ceftazidime in patients on general wards with adequate and impaired renal function receiving regular and guideline-recommended reduced doses of ceftazidime for treatment of infections with Pseudomonas aeruginosa and all bacteria with lower MIC-values.

Healthcare-associated infections in Dutch hospitals during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic hospitals reorganized their resources and delivery of care, which may have affected the number of healthcare-associated infections (HAIs). We aimed to quantify changes in trends in the number of HAIs in Dutch hospitals during the COVID-19 pandemic.

METHODS

National surveillance data from 2016 to 2020 on the prevalence of HAIs measured by point prevalence surveys, and the incidence of surgical site infections (SSIs) and catheter-related bloodstream infections (CRBSIs) were used to compare rates between the pre-pandemic (2016-February 2020) and pandemic (March 2020-December 2020) period.

RESULTS

The total HAI prevalence among hospitalised patients was higher during the pandemic period (7.4%) compared to pre-pandemic period (6.4%), mainly because of an increase in ventilator-associated pneumonia (VAP), gastro-intestinal infections (GIs) and central nervous system (CNS) infections. No differences in SSI rates were observed during the pandemic, except for a decrease after colorectal surgeries (6.3% (95%-CI 6.0-6.6%) pre-pandemic versus 4.4% (95%-CI 3.9-5.0%) pandemic). The observed CRBSI incidence in the pandemic period (4.0/1,000 CVC days (95%-CI 3.2-4.9)) was significantly higher than predicted based on pre-pandemic trends (1.4/1000 (95%-CI 1.0-2.1)), and was increased in both COVID-19 patients and non-COVID-19 patients at the intensive care unit (ICU).

CONCLUSIONS

Rates of CRBSIs, VAPs, GIs and CNS infections among hospitalised patients increased during the first year of the pandemic. Higher CRBSI rates were observed in both COVID-19 and non-COVID-19 ICU population. The full scope and influencing factors of the pandemic on HAIs needs to be studied in further detail.

The effect of an intervention bundle to prevent central venous catheter-related bloodstream infection in a national programme in the Netherlands

INTRODUCTION

Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals.

AIM

This study aimed to determine the impact of an intervention bundle on CRBSI risk.

METHODS

Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression.

FINDINGS

Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36)).

CONCLUSION

Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk.

C‐reactive protein, procalcitonin, and erythrocyte sedimentation rate for the diagnosis of lower urinary tract infection in older people

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

Improving indicator-condition guided testing for HIV in the hospital setting (PROTEST 2·0): A multicenter, interrupted time-series analysis

BACKGROUND

Indicator-condition (IC) guided HIV testing is a feasible and cost-effective strategy to identify undiagnosed people living with HIV (PLHIV), but remains insufficiently implemented. We aimed to promote IC-guided HIV testing in seven ICs.

METHODS

Relevant departments in five hospitals of the Amsterdam region participated. HIV testing among adult patients without known HIV infection but with an IC was assessed using electronic health records during pre-intervention (January 2015-June 2020) and intervention (July 2020-June 2021) periods. The multifaceted intervention included audit and feedback. The primary endpoint was HIV testing ≤3 months before or after IC diagnosis and the effect of the intervention was evaluated using segmented Poisson regression.

FINDINGS

Data from 7986 patients were included, of whom 6730 (84·3%) were diagnosed with an IC in the pre-intervention period and 1256 (15·7%) in the intervention period. The proportion HIV tested ≤3 months before or after IC diagnosis increased from 36.8% to 47.0% (adjusted risk ratio [RR]= 1.16, 95% CI=1.03-1.30, p=0.02). For individual ICs, we observed significant increases in HIV testing among patients with cervical cancer or intraepithelial neoplasia grade 3 (adjusted RR=3.62, 95% CI=1.93-6.79) and peripheral neuropathy (adjusted RR=2.27 95% CI=1.48-3.49), but not the other ICs. Eighteen of 3068 tested patients were HIV positive (0.6%).

INTERPRETATION

Overall IC-guided testing improved after the intervention, but not for all ICs. Variations in effect by IC may have been due to variations in implemented developments, but the effect of separate elements could not be assessed.

FUNDING

HIV Transmission Elimination Amsterdam (H-TEAM) initiative, Aidsfonds (grant number: P-42702).

Shared decision making for women with uncomplicated Cystitis in Primary Care in the Netherlands: a qualitative interview study

BACKGROUND

Urinary tract infections (UTIs) are common, especially among women. Antibiotics are commonly used to treat UTIs, but might not always be necessary, for example in the case of uncomplicated UTIs such as cystitis. Shared decision making (SDM) could reduce the risk of unnecessary antibiotic prescriptions for uncomplicated cystitis. We investigated the current management and the use of SDM for uncomplicated cystitis in primary care.

METHODS

We performed a qualitative semi-structured interview study among 23 women with a history of cystitis, 12 general practitioner (GP) assistants, and 12 GPs in the Netherlands from July to October 2020. All interviews were individually performed by telephone. The data were analyzed through the use of using open and axial coding.

RESULTS

The GP assistants managed the initial diagnostics and treatment of uncomplicated cystitis in all general practices. Usually, antibiotics were considered the standard treatment of cystitis. In most general practices, SDM was not used in the treatment of uncomplicated cystitis, mainly because of a lack of time. Women reported that they valued being involved in the treatment decision-making process, but they were not always involved. Further, both GP assistants and GPs indicated that SDM would improve the care pathway of uncomplicated UTIs.

CONCLUSION

In our study, SDM was infrequently used to help women with uncomplicated cystitis. To reduce the use of antibiotics for uncomplicated UTIs, a tailored intervention is needed to implement SDM for the treatment of uncomplicated cystitis in primary care.

Why Are We Frequently Ordering Urinalyses in Patients without Symptoms of Urinary Tract Infections in the Emergency Department?

(1) Background: In the emergency department (ED), ordering urine tests in patients without symptoms of a urinary tract infection can lead to inappropriate antimicrobial treatment. We aimed to identify factors contributing to the unnecessary ordering of urinalyses in the ED. (2) Methods: An online survey study among nurses and physicians working in the EDs of five hospitals in the Netherlands was conducted. (3) Results: The overall response rate was 26% (221/850; 85 nurses and 136 physicians). The vast majority of the respondents reported knowing when to order urine tests (197/221; 90%). Almost two-thirds of the respondents (145/221; 66%) agreed that they ordered urinalyses because it is rapid and non-invasive to patients. Most nurses (66/86; 78%) said they informed the doctor if they thought the urine test would not contribute to the patient's diagnosis, but only one-third of the physicians agreed with this statement (44/136; 32%). Most respondents (160/221; 72%) thought guidelines or protocols about urinalyses in the ED would be functional. (4) Conclusions: These results suggest urinalyses were frequently ordered in the ED to achieve a fast work process. Nurses and physicians could improve their communication about the indications for urine tests. Developing diagnostic guidelines for urine testing may be convenient.

Fosfomycin Vs Ciprofloxacin as Oral Step-Down Treatment for Escherichia coli Febrile Urinary Tract Infections in Women: A Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial

BACKGROUND

We aimed to determine the noninferiority of fosfomycin compared to ciprofloxacin as an oral step-down treatment for Escherichia coli febrile urinary tract infections (fUTIs) in women.

METHODS

This was a double-blind, randomized, controlled trial in 15 Dutch hospitals. Adult women who were receiving 2-5 days of empirical intravenous antimicrobials for E. coli fUTI were assigned to step-down treatment with once-daily 3g fosfomycin or twice-daily 0.5g ciprofloxacin for 10 days of total antibiotic treatment. For the primary end point, clinical cure at days 6-10 post-end of treatment (PET), a noninferiority margin of 10% was chosen. The trial was registered on Trialregister.nl (NTR6449).

RESULTS

After enrollment of 97 patients between 2017 and 2020, the trial ended prematurely because of the coronavirus disease 2019 pandemic. The primary end point was met in 36 of 48 patients (75.0%) assigned to fosfomycin and 30 of 46 patients (65.2%) assigned to ciprofloxacin (risk difference [RD], 9.6%; 95% confidence interval [CI]: -8.8% to 28.0%). In patients assigned to fosfomycin and ciprofloxacin, microbiological cure at days 6-10 PET occurred in 29 of 37 (78.4%) and 33 of 35 (94.3%; RD, -16.2%; 95% CI: -32.7 to -0.0%). Any gastrointestinal adverse event was reported in 25 of 48 (52.1%) and 14 of 46 (30.4%) patients (RD, 20.8%; 95% CI: 1.6% to 40.0%), respectively.

CONCLUSIONS

Fosfomycin is noninferior to ciprofloxacin as oral step-down treatment for fUTI caused by E. coli in women. Fosfomycin use is associated with more gastrointestinal events.

CLINICAL TRIAL REGISTRATION

Trial NL6275 (NTR6449).

Impact of mucositis on oral bioavailability and systemic exposure of ciprofloxacin Gram-negative infection prophylaxis in patients with haematological malignancies

BACKGROUND

Patients with haematological malignancies frequently endure neutropenia and gastrointestinal (GI)-mucositis after high-dose chemotherapy. In these patients, ciprofloxacin is used for Gram-negative infection prophylaxis.

OBJECTIVES

We investigate ciprofloxacin pharmacokinetics after oral administration in patients with haematological malignancies and explore the impact of GI-mucositis on oral bioavailability and clearance in order to assure adequate systemic exposure.

METHODS

Adult haematological patients from two Dutch University Medical Centres received 500 mg twice daily oral ciprofloxacin for Gram-negative prophylaxis. The ciprofloxacin plasma concentrations were collected at various timepoints after oral ciprofloxacin administration and at various days after completion of chemotherapy. Data obtained after oral and intravenous ciprofloxacin administration in 28 healthy volunteers without mucositis served as a control group (391 samples). For haematological patients the degree of GI-mucositis was assessed using the Daily Gut Score (DGS), plasma citrulline and albumin. Data were analysed by non-linear mixed-effects modelling.

RESULTS

In total, 250 blood samples were collected in 47 patients with a wide variety of haematological malignancies between 0-30 days after start of chemotherapy. Mucositis was generally mild [DGS median (IQR) 1 (1-1) and citrulline 16 μmol/L (12-23)]. The time to Cmax was slower in haematological patients compared with healthy volunteers although no association with the degree of mucositis (defined as DGS or citrulline) could be identified. Ciprofloxacin bioavailability and clearance were 60% and 33.2 L/h, respectively.

CONCLUSIONS

This study supports oral dosing of ciprofloxacin as Gram-negative infection prophylaxis in haematological patients with mild-to-moderate mucositis capable of oral intake.

The Evaluation of an Interprofessional QI Program: A Qualitative Study

Background: Quality Improvement (QI) is the key for every healthcare organization. QI programs may help healthcare professionals to develop the needed skills for interprofessional collaboration through interprofessional education. Furthermore, the role of diversity in QI teams is not yet fully understood. This evaluation study aimed to obtain in-depth insights into the expectations and experiences of different stakeholders of a hospital-wide interprofessional QI program. Methods: This qualitative study builds upon 20 semi-structured interviews with participants and two focus groups with the coaches and program advisory board members of this QI program. Data were coded and analyzed using thematic analysis. Results: Three themes emerged from the analysis: "interprofessional education", "networking" and "motivation: presence with pitfalls". Working within interprofessional project groups was valuable, because participants with different experiences and skills helped to move the QI project forward. It was simultaneously challenging because IPE was new and revealed problems with hierarchy, communication and planning. Networking was also deemed valuable, but a shared space to keep in contact after finalizing the program was missing. The participants were highly motivated to finish their QI project, but they underestimated the challenges. Conclusions: A hospital-wide QI program must explicitly pay attention to interprofessional collaboration and networking. Leaders of the QI program must cherish the motivation of the participants and make sure that the QI projects are realistic.

Development and Validation of a Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) Assay for the Determination of Total and Unbound Ciprofloxacin Concentrations in Human Plasma

BACKGROUND

Although unbound ciprofloxacin is responsible for antibacterial effects, assays measuring the unbound drug plasma concentrations are scarce. This study aimed to develop and validate a rapid, reproducible, and sensitive liquid chromatography-tandem mass spectrometry assay for the determination of total and unbound ciprofloxacin plasma concentrations.

METHODS

The determination of total ciprofloxacin concentrations required a 10 μL sample, while for unbound ciprofloxacin concentrations, it was 100 μL. Unbound ciprofloxacin was separated from protein-bound ciprofloxacin through ultrafiltration. A deuterated internal standard was used, and the sample preparation involved protein precipitation. The method was fully validated over a concentration range of 0.02-5.0 mg/L, according to the US Food and Drug Administration guidelines. In addition, its clinical application was demonstrated.

RESULTS

The total run time was 1.5 minutes. For total ciprofloxacin plasma concentrations, the mean accuracy ranged from 94.5% to 105.0% across the validated range, the intraday imprecision was ≤7.6%, and the interday imprecision was ≤9.8%. For unbound ciprofloxacin plasma concentrations, the mean accuracy ranged from 92.8% to 102.1% across the validated range, the intraday imprecision was ≤7.0%, and the interday imprecision was ≤9.6%. Ciprofloxacin in plasma and ultrafiltrate remained stable for at least 96 hours at room temperature, at least 4 years at -80°C, and at least 3 freeze/thaw cycles (-80°C), with a minimum interval of 24 hours.

CONCLUSIONS

The presented method is precise and accurate. It has been implemented in clinical care and research projects at a university hospital, permitting rapid determination of total and unbound ciprofloxacin.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial

OBJECTIVE

To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents.

DESIGN

Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual.

SETTING AND PARTICIPANTS

212 residents with suspected UTI, from 16 NHs in the Netherlands.

METHODS

Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level.

RESULTS

295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02).

CONCLUSION AND IMPLICATIONS

Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.

A randomised controlled trial testing the efficacy of Fit after COVID, a cognitive behavioural therapy targeting severe post-infectious fatigue following COVID-19 (ReCOVer): study protocol

BACKGROUND

Coronavirus disease 2019 (COVID-19) results in debilitating long-term symptoms, often referred to as Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), in a substantial subgroup of patients. One of the most prevalent symptoms following COVID-19 is severe fatigue. Prompt delivery of cognitive behavioural therapy (CBT), an evidence-based treatment that has shown benefit in reducing severe fatigue in other conditions, may reduce post-COVID-19 fatigue. Based on an existing CBT protocol, a blended intervention of 17 weeks, Fit after COVID, was developed to treat severe fatigue after the acute phase of infection with SARS-CoV-2.

METHOD

The ReCOVer study is a multicentre 2-arm randomised controlled trial (RCT) to test the efficacy of Fit after COVID on severe post-infectious fatigue. Participants are eligible if they report severe fatigue 3 up to and including 12 months following COVID-19. One hundred and fourteen participants will be randomised to either Fit after COVID or care as usual (ratio 1:1). The primary outcome, the fatigue severity subscale of the Checklist Individual Strength (CIS-fatigue), is assessed in both groups before randomisation (T0), directly post CBT or following care as usual (T1), and at follow-up 6 months after the second assessment (T2). In addition, a long-term follow-up (T3), 12 months after the second assessment, is performed in the CBT group only. The primary objective is to investigate whether CBT will lead to a significantly lower mean fatigue severity score measured with the CIS-fatigue across the first two follow-up assessments (T1 and T2) as compared to care as usual. Secondary objectives are to determine the proportion of participants no longer being severely fatigued (operationalised in different ways) at T1 and T2 and to investigate changes in physical and social functioning, in the number and severity of somatic symptoms and in problems concentrating across T1 and T2.

DISCUSSION

This is the first trial testing a cognitive behavioural intervention targeting severe fatigue after COVID-19. If Fit after COVID is effective in reducing fatigue severity following COVID-19, this intervention could contribute to alleviating the long-term health consequences of COVID-19 by relieving one of its most prevalent and distressing long-term symptoms.

TRIAL REGISTRATION

Netherlands Trial Register NL8947 . Registered on 14 October 2020.

Supporting resident well-being on and outside the ICU during the COVID-19 pandemic: the use and value of institutional interventions and individual strategies

During the COVID-19 pandemic, resident well-being has been shown to be at risk, which may interfere with residents' process of professional development during their educational trajectory. Therefore, we developed a well-being program for residents, aimed to help residents maintain their well-being during the COVID-19 pandemic. We explored residents' perceptions of their well-being as well as their perceived support of the well-being program during the COVID-19 pandemic. We invited all internal medicine residents and residents working in the ICU (N = 203) of one academic medical center to participate. The well-being program included a combination of (1) well-being measurements and (2) organizational support. The repeated well-being measurements involved a well-being survey on six measurement points from April to June 2020, and organizational support combined the provision of institutional interventions and promotion of individual strategies to help residents maintain their well-being during a pandemic. In total, 103 residents (50.1%) participated, showing that residents working in the ICU reported significantly lower levels of mental well-being than residents not working on the ICU. Furthermore, residents did not perceive the institutional interventions to benefit their well-being, while residents' reported engagement in individual strategies was significantly positively associated with their well-being. As ICU residents reported lower levels of mental well-being, well-being programs need to address ICU-specific stressors while enhancing supervision and peer support. Furthermore, the individual strategies of the well-being program should be tailored to residents' well-being needs as these were positively associated with resident well-being.

Rationale, design and initial results of an educational intervention to improve provider-initiated HIV testing in primary care

OBJECTIVES

In the Netherlands, general practitioners (GPs) perform two-thirds of sexually transmitted infection (STI) consultations and diagnose one-third of HIV infections. GPs are, therefore, a key group to target to improve provider-initiated HIV testing. We describe the design and implementation of an educational intervention to improve HIV testing by Amsterdam GPs and explore trends in GPs' testing behaviour.

METHODS

Interactive sessions on HIV and STI using graphical audit and feedback started in 2015. Participating GPs developed improvement plans that were evaluated in follow-up sessions. Laboratory data on STI testing by Amsterdam GPs from 2011 to 2017 were collected for graphical audit and feedback and effect evaluation. The primary outcome was the HIV testing rate: number of HIV tests per 10 000 person-years (PY). Secondary endpoints were chlamydia and gonorrhoea testing rates and HIV positivity ratios.

RESULTS

Since 2015, 41% of GPs participated. HIV testing rate declined from 2011 to 2014 (from 175 to 116 per 10 000 PY), more in women than men (176 to 101 versus 173 to 132), and stabilized from 2015 to 2017. The HIV positivity ratio declined from 0.8% in 2011 to 0.5% in 2017. From 2011 to 2017, chlamydia and gonorrhoea testing rates declined in women (from 618 to 477 per 10 000 PY) but remained stable in men (from 270 to 278).

CONCLUSIONS

The stabilization of the downward trend in HIV testing coincided with this educational intervention. Follow-up data are needed to formally assess the intervention's impact on GP testing behaviour whilst considering contextual factors and secular trends.

A multicentre cluster-randomized clinical trial to improve antibiotic use and reduce length of stay in hospitals: comparison of three measurement and feedback methods

BACKGROUND

Various metrics of hospital antibiotic use might assist in guiding antimicrobial stewardship (AMS).

OBJECTIVES

To compare patient outcomes in association with three methods to measure and feedback information on hospital antibiotic use when used in developing an AMS intervention.

METHODS

Three methods were randomly allocated to 42 clusters from 21 Dutch hospitals: (1) feedback on quantity of antibiotic use [DDD, days-of-therapy (DOT) from hospital pharmacy data], versus feedback on (2) validated, or (3) non-validated quality indicators from point prevalence studies. Using this feedback together with an implementation tool, stewardship teams systematically developed and performed improvement strategies. The hospital length of stay (LOS) was the primary outcome and secondary outcomes included DOT, ICU stay and hospital mortality. Data were collected before (February-May 2015) and after (February-May 2017) the intervention period.

RESULTS

The geometric mean hospital LOS decreased from 9.5 days (95% CI 8.9-10.1, 4245 patients) at baseline to 9.0 days (95% CI 8.5-9.6, 4195 patients) after intervention (P < 0.001). No differences in effect on LOS or secondary outcomes were found between methods. Feedback on quality of antibiotic use was used more often to identify improvement targets and was preferred over feedback on quantity of use. Consistent use of the implementation tool seemed to increase effectiveness of the AMS intervention.

CONCLUSIONS

The decrease in LOS versus baseline likely reflects improvement in the quality of antibiotic use with the stewardship intervention. While the outcomes with the three methods were otherwise similar, stewardship teams preferred data on the quality over the quantity of antibiotic use.

Registration of catheter-related complications in adverse events reporting systems: a major underestimation of the real complication practice

Reporting and learning from preventable adverse events is crucial to improve patient safety. Although physicians should file and analyse adverse events by law in The Netherlands, it is unknown if these reporting systems are sufficiently used in clinical practice. This study is a substudy of the multicenter RICAT trial, a successful quality improvement project to reduce inappropriate use of intravenous and urinary catheters in medical wards in seven hospitals, in which we screened 5696 patients and documented 803 catheter-related complications. We also checked the adverse events reporting systems of these patients and found that only 13 (1.6%) of 803 catheter-related complications were registered. Of the infectious complications only five (10.9%) of 46 catheter-associated bloodstream infections and urinary tract infections were registered. We conclude that the reported complications were a major underestimation of the real complication practice in medical wards in The Netherlands.

The RICAT trial is registered at Netherlands Trial Register, trial NL5438.

Nitrofurantoin 100 mg versus 50 mg prophylaxis for urinary tract infections, a cohort study

OBJECTIVES

Guidelines do not distinguish between 50 mg or 100 mg nitrofurantoin as daily prophylaxis for recurrent urinary tract infection (UTI), although 50 mg might have a better safety profile. Our objective was to compare the effectiveness and safety of both regimens.

METHODS

Data were retrospectively collected from 84 Dutch GP practices between 2013 and 2020. Nitrofurantoin prescriptions of 100 mg and 50 mg every 24 hours in women were included. Cox proportional hazard regression analysis was used to calculate hazard ratios on first episode of UTI, pyelonephritis and (adverse) events. Patients were followed for the duration of consecutive repeated prescriptions, assuming non-informative right censoring, up to 1 year.

RESULTS

Nitrofurantoin prophylaxis was prescribed in 1893 patients. Median lengths of follow up were 90 days (interquartile range (IQR) 37-179 days) for 100 mg (n = 551) and 90 days (IQR 30-146 days) for 50 mg (n = 1342) with few differences in baseline characteristics between populations. Under 100 mg and 50 mg, 82/551 (14.9%) and 199/1342 (14.8%) developed UTI and 46/551 (8.3%) and 81/1342 (6.0%) developed pyelonephritis, respectively. Adjusted HRs of 100 mg versus 50 mg were 1.01 (95% CI 0.78-1.30) on first UTI, 1.37 (95% CI 0.95-1.98) on first pyelonephritis episode, 1.82 (95% CI 1.20-2.74) on first consultation for cough, 2.68 for dyspnoea (95% CI 1.11-6.45) and 2.43 for nausea (95% CI 1.03-5.74).

CONCLUSION

Daily prophylaxis for recurrent UTI with 100 mg instead of 50 mg nitrofurantoin was associated with an equivalent hazard on UTI or pyelonephritis, and a higher hazard on cough, dyspnoea and nausea. We recommend 50 mg nitrofurantoin as daily prophylaxis.

The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment

BACKGROUND

Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy.

METHODS

We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.'s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose.

RESULTS

We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p < .001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p = .971) than to other errors (115 s vs 136 s, p = .082).

CONCLUSIONS

We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.

Deimplementation strategy to reduce overtreatment of asymptomatic bacteriuria: a study protocol for a stepped-wedge cluster randomised trial

INTRODUCTION

Antimicrobial treatment of asymptomatic bacteriuria (ASB) is one of the most common unnecessary uses of antimicrobials. Earlier studies have shown that the prevalence of this inappropriate treatment ranges from 45% to 83%. Multifaceted interventions based on international guidelines and antimicrobial stewardship can decrease overtreatment of ASB. We have designed a study protocol with the main objective of reducing overtreatment of ASB by 50% through use of a deimplementation strategy.

METHODS AND ANALYSIS

We will use a stepped-wedge cluster randomised design, comparing outcomes before and after introduction of our intervention in the emergency department (ED) of five hospitals (clusters) in the Netherlands. All patients (≥18 years old) who have a urine test performed in the ED will be screened for eligibility. The deimplementation strategy consists of a combination of interventions, including education, audit and feedback. The primary endpoint is overtreatment of ASB in patients without risk factors (eg, pregnancy, planned invasive urological procedures and neutropenia). Secondary endpoints are the duration of antimicrobial treatment for ASB, the number of urine cultures and urinalysis per 1000 patients, and overtreatment of positive urinalysis in asymptomatic patients.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the medical ethics research committee of the Academic Medical Centre (Amsterdam, the Netherlands) with a waiver for informed consent. Local feasibility was obtained by the local institutional review boards of all participating hospitals. Our study aims to reduce inappropriate screening and treatment of ASB in EDs, improve healthcare quality, lower the increase in antimicrobial resistance and save costs. If proven (cost)-effective, this study provides a well-suited strategy for a nationwide approach to reduce overtreatment of ASB. Relevant results of our study will be disseminated through publications in peer-reviewed journals and presentations at relevant (scientific) conferences.

TRIAL REGISTRATION NUMBER

NL8242; Pre-results.

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

BACKGROUND

Choosing Wisely aims to reduce low-value care to improve quality and lower costs. In the Netherlands, this campaign offers three recommendations for internal medicine applicable in emergency departments (EDs): (1) do not place an indwelling urinary catheter in non-critically ill patients who can void; (2) do not order plain abdominal radiographs in patients with acute abdominal pain; and (3) discuss whether treatment limitations are needed. This quality improvement project aims to increase the implementation of the recommendations by patient information leaflets.

METHODS

In a prospective before-after study, we collected data every other week during baseline and intervention periods (both 7 months) in two university medical centres. The primary outcomes were the adherence rates to the recommendations.

RESULTS

805 patients visited the EDs for internal medicine, of whom 391 (48.6%) were hospitalised. Only 153 (19%) patients received the information leaflet. We found no change in implementation rates of the recommendations after the introduction of the patient information leaflet. In the baseline period, 28 patients received a urinary catheter, of whom 5 (17.9%) had no appropriate indication, compared with 4 (25.0%) of 16 patients in the intervention period (p=0.572). Unnecessary abdominal X-ray occurred once in the baseline period and not in the intervention period. Treatment limitations were not reported in 13 (6.5%) of 200 hospitalised patients in the baseline period, and in 17 (8.9%) of 191 patients in the intervention period (p=0.373).

CONCLUSIONS

Patient information leaflets did not increase the implementation of Choosing Wisely recommendations, which can be due to a high baseline rate and a poor dissemination of leaflets. Our ED seems not to be a practicable setting for dissemination of leaflets, since staff engagement was not possible due to high workload and shortage of qualified nursing staff in the Netherlands.

CD8 and CD4 T Cell Populations in Human Kidneys

Background: At border sites, and in internal organs, tissue resident memory T cells (T_RM) contribute to the immune barrier against pathogens like viruses, bacteria, fungi, and cancer. However, information on the presence and function of these cells in the human kidney is scant. In order to better understand the T cell-mediated immunological defense in this organ, we aimed to determine phenotypic and functional aspects of CD8 and CD4 T cells present in healthy and allograft kidney tissue. Methods: Using multichannel flow cytometry, we assessed the phenotype and function of T cells in healthy renal tissue samples (n = 5) and kidney allograft tissue (n = 7) and compared these aspects to T cells in peripheral blood from healthy controls (n = 13). Results: Kidney tissue samples contained substantial amounts of CD8 and CD4 T cells. In contrast to the circulating cells, kidney T cells frequently expressed CD69 and CD103, and were more often actively cycling. Furthermore, nearly all kidney T cells expressed CXCR3, and often expressed CXCR6 compared to T cells in the circulation. Markedly, kidney T cells produced greater quantities of IFNγ than circulating cells and were frequently polyfunctional. Conclusion: Functional T cells with the characteristic traits of T_RM reside in human kidney tissues. These cells are more often actively cycling and frequently express CXCR3 and CXCR6.

How many urinalysis and urine cultures are necessary?

BACKGROUND

Urinalysis and urine culture are two of the most commonly ordered tests. A positive urine test in asymptomatic patients often leads to overtreatment. Antimicrobials for asymptomatic bacteriuria is one of the most common unnecessary treatments. We aimed to explore the current ordering patterns of urinalysis and cultures.

METHODS

This is a substudy of the multicentre RICAT-trial, a successful quality improvement project to reduce inappropriate use of intravenous and urinary catheters in seven hospitals in the Netherlands. Adult patients with a (central or peripheral) venous or urinary catheter admitted to internal medicine and non-surgical subspecialty wards were eligible for inclusion. Data were collected every other week during baseline (seven months) and intervention periods (seven months). The primary outcome was the proportion of urine cultures performed following a negative urinalysis, i.e. dipstick and/or microscopic analysis, within 24 h.

RESULTS

Between September 2016 and April 2018, we included 3748 patients, of which 3111 (83%) were admitted from the emergency department. Urinalysis and/or urine cultures were obtained in 2610 (70%) of 3748 patients. 626 (23.7%) of 2636 urine cultures and 1351 (55.8%) of 2419 microscopic analysis were unnecessary performed after a negative urinalysis. Cancelling urine testing orders after a negative dipstick would have saved almost € 19.500 during the study period in these seven hospitals.

CONCLUSION

Unnecessary urine testing is frequent in non-surgical patients in the Netherlands. We need to take action to reduce unnecessary urinalysis and cultures, and thereby probably reduce overtreatment of asymptomatic bacteriuria.

Does dose reduction of renally cleared antibiotics in patients with impaired renal function lead to adequate drug exposure? A systematic review

BACKGROUND

There is inconsistency between many guidelines in the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function.

OBJECTIVES

This systematic review summarizes the available evidence on the adequacy of the recommended dose reduction in terms of achieving sufficient antibiotic drug exposure or pharmacokinetic/pharmacodynamic target attainment after treatment with these reduced doses.

DATA SOURCES

We systematically searched Ovid Medline and Embase from inception (respectively 1946 and 1947) through July 2019.

STUDY ELIGIBILITY CRITERIA

All studies reporting antibiotic drug exposure and/or pharmacokinetic/pharmacodynamic (PK/PD) target attainment after dose reduction of antibiotics in patients with impaired renal function.

PARTICIPANTS

Adult patients with or without infections.

INTERVENTIONS

Administration of reduced doses of antibiotics (orally, intravenously or intramuscularly).

METHODS

The reduced dose was considered adequate when the most relevant parameters of drug exposure or PK/PD target attainment in patients with impaired renal function were within a range of 80% to 125% of that patients with adequate renal function receiving a regular dose (reference) or when PK/PD target attainment was attained in at least 90% of the patients with impaired renal function, regardless of the lack of a reference group.

RESULTS

Twenty-seven of the 4202 identified studies were included. The quality of 15 of 27 studies was fair, and most studies were of β-lactams (12/27). Best evidence was available for meropenem: four studies were included, of which two studies were of good quality. Drug exposure for meropenem is 158% to 286% higher in patients with impaired renal function receiving reduced doses compared to patients with adequate renal function receiving regular doses. For all other antibiotics, a maximum of one good-quality study could be identified.

CONCLUSIONS

No good-quality evidence on the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function is present, with the exception of meropenem.

A healthcare failure mode and effect analysis to optimise the process of blood culture performance

BACKGROUND

Blood cultures are essential diagnostic tools to identify pathogens in systemic infections. However, logistics of blood culture performance is often suboptimal. This study analyses the pre-analytic phase of blood culture processing through different types of risk assessments.

METHODS

We performed direct observations to gain in-depth knowledge of the root causes of suboptimal blood culture performance. These findings were summarised in a Bow-Tie chart. We then utilised a healthcare failure mode and effect analysis to prioritise failures per step in the process and to organise improvement activities. Finally, improvement actions were planned.

RESULTS

Not obtaining a second set of blood cultures in the logistics of blood culture performance had the highest priority for action. Several failure modes, including human and system factors, were identified. Improvement actions included training and clinical lessons for nurses in the emergency department, updating hospital search engines to ease identification of relevant protocols, and an evaluation of the workload at the emergency department. Failure modes caused by human factors appear easy to address, however changing human behaviour is challenging.

CONCLUSIONS

The analysis provided useful insight into the different steps in the logistics of blood culture performance and facilitated the organisation of actions focused on addressing the most urgent root causes.

Implementation of 'Choosing Wisely Netherlands' for internal medicine

BACKGROUND

The Choosing Wisely campaign aims to reduce low-value care to improve quality and lower healthcare costs. Our objective was to determine the current implementation of the Choosing Wisely Netherlands campaign and the 10 recommendations (released in 2014) for internal medicine.

METHODS

We actively surveyed physicians and residents in the departments of internal medicine in 13 hospitals in the Netherlands. The survey was performed during a presentation about Choosing Wisely and we asked whether they thought that the recommendations were implemented.

RESULTS

Between May and November 2018, we surveyed 281 physicians and residents, of which we received 2625 answers (response rate 85%). We found that 178 (68.5%) of 260 physicians were unaware of the Choosing Wisely campaign. For the implementation of recommendations, 1506 (75.2%) of 2003 answers stated that physicians applied the recommendations in clinical practice. We found no differences in implementation of physicians who were aware or unaware of the campaign, respectively 529 (76.1%) of 695 versus 854 (74.2%) of 1151 of the recommendations were implemented; p = 0.357. The recommendation that was implemented least was 'Do not routinely order coagulation tests before invasive procedures', in which 28% stated that they applied this in clinical practice.

CONCLUSION

Four years after the introduction, only one-third of physicians and residents of internal medicine were aware of the Choosing Wisely Netherlands campaign. Nevertheless, most Choosing Wisely recommendations were implemented sufficiently in clinical practice. There is room for improvement, mainly in recommendations that need a multidisciplinary approach.

Pharmacokinetic/pharmacodynamic target attainment of ciprofloxacin in adult patients on general wards with adequate and impaired renal function

Limited prospective data on pharmacokinetic/pharmacodynamic (PK/PD) target attainment of ciprofloxacin in patients with adequate and impaired renal function (eGFR <30 mL/min/1.73m²) are available in the literature. We aimed to investigate whether the PK/PD target (AUC/MIC ≥125) is attained in patients with adequate and impaired renal function receiving regular and reduced ciprofloxacin doses. This prospective observational cohort study included adult patients on general wards treated with ciprofloxacin. Three blood samples per patient were obtained for ciprofloxacin concentration measurement. Individual AUCs were calculated using a population PK model developed by non-linear mixed-effects modelling. Forty patients were included, of whom eight had impaired renal function and were treated with a guideline-recommended reduced dose. Using the clinical breakpoint MIC of the most isolated bacteria (Escherichia coli, 0.25 mg/L), AUC_0-24/MIC ≥125 was attained in 13/32 (41%) patients with adequate renal function receiving regular doses and in 1/8 (13%) patients with impaired renal function receiving reduced doses. Median drug exposure (AUC_0-24) for patients with impaired renal function was 19.0 [interquartile range (IQR) 14.2-23.3] mg/L•h, which was statistically significantly lower than that for patients with adequate renal function [29.3 (IQR 25.0-36.0) mg/L•h] (P < 0.01). AUC_0-24/MIC ≥125 is not attained in the majority of adult patients on general wards for clinically relevant bacteria with MICs at or just below the clinical breakpoint. The risk of not attaining the target appears to be highest in patients with impaired renal function receiving guideline-recommended reduced doses, as drug exposure is significantly lower in these patients.

Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial

BACKGROUND

Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process.

METHODS

A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals.

DISCUSSION

This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care.

TRIAL REGISTRATION

The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555 .

Tissue-resident mucosal-associated invariant T (MAIT) cells in the human kidney represent a functionally distinct subset

Mucosal‐associated invariant T (MAIT) cells are innate‐like T‐cells that recognize bacterial riboflavin metabolites. They are present in human blood but are abundant at barrier sites, including the liver, lungs, and kidneys, where they possess a CD69⁺/CD103^+/− tissue‐resident phenotype. In renal tissue, MAIT cells likely defend against the ascending uropathogens responsible for urinary tract infections (UTIs), which are common, especially among renal transplant recipients (RTRs). Nevertheless, the functional role for MAIT cells in renal tissue and the influence of renal transplantation on MAIT cells remains unclear. Using multiparameter flow cytometry and the MR1‐tetramer, we characterized MAIT cell phenotype and function in healthy renal tissue (n = 6), renal transplants explanted after allograft failure (n = 14) and in blood from healthy controls (n = 20) and RTRs before and 1‐year after transplantation (n = 21). MAIT cells in renal tissue constitute a distinct CD69⁺CD103^+/− population that displays typical phenotypic features of tissue‐resident T‐cells and is skewed toward IL‐2, GM‐CSF, and IL‐17A production upon stimulation. The circulating MAIT cell population was not decreased in number in RTRs pre‐ or post‐transplantation. Tissue‐resident MAIT cells in the kidney represent a functionally distinct population. This shows how MAIT cells in the kidney may be involved in the protection against microorganisms.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Prevalence and risk factors of inappropriate use of intravenous and urinary catheters in surgical and medical patients

BACKGROUND

Previously, the RICAT (Reduction of Inappropriate use of intravenous and urinary CATheters) study had been conducted by ourselves to reduce inappropriate use of intravenous and urinary catheters in medical wards to prevent healthcare-associated infections.

AIM

To compare surgical and medical wards, and to determine risk factors for inappropriate catheter use.

METHODS

A cross-sectional study was performed from October, 2017, to May, 2018, in surgical wards of two university hospitals in the Netherlands. Patients were prospectively observed every other week for seven months. Inappropriate use was compared with non-surgical wards in the RICAT study.

FINDINGS

In all, 409 surgical patients were included, and they were compared with 1781 medical patients. Inappropriate use occurred in 36 (8.5%) out of 425 peripheral intravenous catheters in 373 surgical patients, compared to 400 (22.9%) out of 1747 peripheral intravenous catheters in 1665 medical patients, a difference of 14.4% (95% confidence interval (CI): 11.1-17.8; P < 0.001). Inappropriate use of urinary catheters occurred in 14 (10.4%) out of 134 surgical patients, compared to 105 (32.4%) out of 324 medical patients, a difference of 22.0% (95% CI: 14.7-29.2; P < 0.001). Subgroup analysis in the two university hospitals confirmed these differences. The main risk factor for inappropriate use of peripheral intravenous catheters was admission in medical wards (odds ratio (OR): 3.50; 95% CI: 2.15-5.69), which was also one of the main risk factors for urinary catheters (OR: 2.75; 95% CI: 1.36-5.55).

CONCLUSION

Inappropriate use of catheters is more common in medical wards compared to surgical wards. Prevention strategies to reduce healthcare-associated infections should primarily focus on sites with high prevalence of inappropriate use.

De-implementation strategy to reduce inappropriate use of intravenous and urinary catheters (RICAT): a multicentre, prospective, interrupted time-series and before and after study

BACKGROUND

Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections.

METHODS

In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438.

FINDINGS

Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p<0·0001). Time-series analyses showed an absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6·65% (95% CI 2·47 to 10·82, p=0·011). Inappropriate use of urinary catheters occurred in 105 (32·4%, 95% CI 27·3 to 37·8) of 324 patients in the baseline group compared with 96 (24·1%, 20·0 to 28·6) of 398 patients in the intervention group (IRR 0·74, 95% CI 0·56 to 0·98, p=0·013). Time-series analyses showed an absolute reduction in inappropriate use of urinary catheters of 6·34% (95% CI -12·46 to 25·13, p=0·524).

INTERPRETATION

Our de-implementation strategy reduced inappropriate use of short peripheral intravenous catheters in patients who were not in the intensive care unit. The reduction of inappropriate use of urinary catheters was substantial, yet not statistically significant in time-series analysis due to a small sample size. The strategy appears well suited for broad-scale implementation to reduce health care-associated infections.

FUNDING

Netherlands Organisation for Health Research and Development.

Circulating mucosal-associated invariant T cells in subjects with recurrent urinary tract infections are functionally impaired

Background

Urinary tract infection recurrence is common, particularly in women and immunocompromised patients, such as renal transplant recipients (RTRs). Mucosal‐associated invariant T (MAIT) cells play a role in the antibacterial response by recognizing bacterial riboflavin metabolites produced by bacteria such as Escherichia coli. Here, we investigated whether MAIT cells are involved in the pathogenesis of recurrent urinary tract infections (RUTIs).

Methods

Using multichannel flow cytometry, we characterized the MAIT cell phenotype and function in blood from immunocompetent adults with (n = 13) and without RUTIs (n = 10) and in RTRs with (n = 9) and without RUTIs (n = 10).

Results

There were no differences in the numbers of MAIT cells between the study groups. MAIT cells in patients with RUTI expressed T‐bet more often than those in controls. MAIT cells from immunocompetent RUTI participants required more antigen‐presenting cells coincubated with E. coli to evoke a similar cytokine and degranulation response than those from controls. This effect was absent in the RTR with RUTI vs RTR control groups, where the overall percentage of MAIT cells that responded to stimulation was already reduced.

Conclusion

Circulating MAIT cells in immunocompetent individuals with RUTIs respond to bacterial stimuli with reduced efficacy, which suggests that they are involved in the pathogenesis of RUTIs.

Knowledge and use of antibiotics in six ethnic groups: the HELIUS study

Background

The increase of antimicrobial resistance, mainly due to increased antibiotic use, is worrying. Preliminary evidence suggests that antibiotic use differs across ethnic groups in the Netherlands, with higher use in people of non-Dutch origin. We aimed to determine whether appropriate knowledge and use of antibiotics differ by ethnicity and whether knowledge on antibiotics is associated with antibiotic use.

Methods

We performed a cross-sectional study analyzing baseline data (2011–2015) from a population-based cohort (HELIUS study), which were linked to data from a health insurance register. We included 21,617 HELIUS participants of South-Asian Surinamese, African-Surinamese, Turkish, Moroccan, Ghanaian, and Dutch origin. Fifteen thousand seven participants had available prescription data from the Achmea Health Data-base (AHD) in the year prior to their HELIUS study visit. Participants were asked five questions on antibiotic treatment during influenza-like illness, pneumonia, fever, sore throat and bronchitis, from which higher versus lower antibiotic knowledge level was determined. Number of antibiotic prescriptions in the year prior to the HELIUS study visit was used to determine antibiotic use.

Results

The percentage of individuals with a higher level of antibiotic knowledge was lower among all ethnic minority groups (range 57 to 70%) compared to Dutch (80%). After correcting for baseline characteristics, including medical conditions, first-generation African Surinamese and Turkish migrants received a significantly lower number of antibiotic prescriptions compared to individuals of Dutch origin. Only second-generation Ghanaian participants received more prescriptions compared to Dutch participants (aIRR 2.09, 95%CI 1.06 to 4.12). Higher level of antibiotic knowledge was not significantly associated with the number of prescriptions (IRR 0.92, 95%CI 0.85 to 1.00).

Conclusions

Levels of antibiotic knowledge varied between ethnic groups, but a lower level of antibiotic knowledge did not correspond with a higher number of antibiotic prescriptions.

Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys

BACKGROUND

Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs).

AIM

To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016.

METHODS

In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals.

FINDINGS

PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)).

CONCLUSION

Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

Not feeling ready to go home: a qualitative analysis of chronically ill patients' perceptions on care transitions

QUALITY PROBLEM

Unplanned hospital readmissions frequently occur and have profound implications for patients. This study explores chronically ill patients' experiences and perceptions of being discharged to home and then acutely readmitted to the hospital to identify the potential impact on future care transition interventions.

INITIAL ASSESSMENT AND IMPLEMENTATION

Twenty-three semistructured interviews were conducted with chronically ill patients who had an unplanned 30-day hospital readmission at a university teaching hospital in the Netherlands.

CHOICE OF SOLUTION

A constructive grounded theory approach was used for data analysis.

EVALUATION

The core category identified was 'readiness for hospital discharge,' and the categories related to the core category are 'experiencing acute care settings' and 'outlook on the recovery period after hospital discharge.' Patients' readiness for hospital discharge was influenced by the organization of hospital care, patients' involvement in decision-making and preparation for discharge. The experienced difficulties during care transitions might have influenced patients' ability to cope with challenges of recovery and dependency on others.

LESSONS LEARNED

The results demonstrated the importance of assessing patients' readiness for hospital discharge. Health care professionals are recommended to recognize patients and guide them through transitions of care. In addition, employing specifically designated strategies that encourage patient-centered communication and shared decision-making can be vital in improving care transitions and reduce hospital readmissions. We suggest that health care professionals pay attention to the role and capacity of informal caregivers during care transitions and the recovery period after hospital discharge to prevent possible postdischarge problems.

Safe handovers for every patient: an interrupted time series analysis to test the effect of a structured discharge bundle in Dutch hospitals

OBJECTIVE

Patient handovers are often delayed, patients are hardly involved in their discharge process and hospital-wide standardised discharge procedures are lacking. The aim of this study was to implement a structured discharge bundle and to test the effect on timeliness of medical and nursing handovers, length of hospital stay (LOS) and unplanned readmissions.

DESIGN

Interrupted time series with six preintervention and six postintervention data collection points (September 2015 to June 2017).

SETTING

Internal medicine and surgical wards PARTICIPANTS: Patients (≥18 years) admitted for more than 48 hours to surgical or internal medicine wards.

INTERVENTION

The Transfer Intervention Procedure (TIP), containing four elements: planning the discharge date within 48 hours postadmission; arrangements for postdischarge care; preparing handovers and personalised patient discharge letter; and a discharge conversation 12-24 hours before discharge.

OUTCOME MEASURES

The number of medical and nursing handovers sent within 24 hours. Secondary outcomes were median time between discharge and medical handovers, LOS and unplanned readmissions.

RESULTS

Preintervention 1039 and postintervention 1052 patient records were reviewed. No significant change was observed in the number of medical and nursing handovers sent within 24 hours. The median (IQR) time between discharge and medical handovers decreased from 6.15 (0.96-15.96) to 4.08 (0.33-13.67) days, but no significant difference was found. No intervention effect was observed for LOS and readmission. In subgroup analyses, a reduction of 5.6 days in the median time between discharge and medical handovers was observed in hospitals with high protocol adherence and much attention for implementation.

CONCLUSION

Implementation of a structured discharge bundle did not lead to improved timeliness of patient handovers. However, large interhospital variation was observed and an intervention effect on the median time between discharge and medical handovers was seen in hospitals with high protocol adherence. Future interventions should continue to create awareness of the importance of timely handovers.

TRIAL REGISTRATION NUMBER

NTR5951; Results.